Senior Credentialing Representative - Quality Auditor

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities.

About the role

The Senior Credentialing Representative is responsible for ensuring that credentialing information and data meets internal and external quality standards and requirements. Internal audits are performed against established standards for all credentialing and recredentialing functions within the Credentialing Center of Excellence (CCoE). The SCRA will document findings, identify trends, and recommend opportunities for improvement.

Location: Remote, Nationwide
Schedule: Monday to Friday, 8 AM - 5 PM
You will enjoy the flexibility to telecommute from anywhere within the U.S.

Responsibilities

• Performs daily audits of credentialing and recredentialing files utilizing standardized audit template
• Ensures audits are performed within established timeframes
• Communicates identified errors to credentialing representatives and specialists utilizing established processes
• Participates in audit result review and track and trend of results
• Participates in root cause analysis
• Reviews repeat errors for potential training opportunities
• Provides explanations and interpretations within area of expertise
• Identifies potential process improvement needs to workflows and procedures
• Communicates potential and identified trends to leadership
• Collect and review credentialing files and materials for submission to delegating health plans at time of initial and annual delegation oversight audits
• Collect and review submitted sub-delegated files and materials at time of pre-assessment and annual delegation oversight audits
• Other department duties as assigned

Requirements

• High School Diploma/GED
• 2+ years of experience in Credentialing
• 1+ years of proven consistent quality audit scores passing or exceeding requirements
• 1+ years of experience using credentialing software or software managing provider information

Skills

• Demonstrated understanding of credentialing information processes
• Established knowledge of credentialing requirements to include NCQA, CMS, and state-specific regulations
• Attention to detail, ability to identify inconsistencies and missing information
• Consistently delivers excellent quality of credentialing files processed
• Analytical and critical thinking skills
• Ability to research and evaluate credentialing criteria when questions or discrepancies are presented
• Strong communication skills, ability to communicate clearly and professionally in written or oral formats
• Ability to identify problems, analyze data and recommend solutions
• Ability to maintain confidential information in accordance with Company policies, state, and federal regulations
• Ability to manage detail and work with accuracy
• Ability to acquire knowledge of technical resources within the organization
• Ability to work independently
• Ability to establish and maintain cooperative working relationships with individuals at all levels including teammates from other teams
• Ability to work with frequent interruptions
• Ability to prioritize work and skill in working effectively under deadlines and changing priorities
• Demonstrated knowledge of Microsoft Office applications such as Word, Excel, and Outlook
• Intermediate level skills working in Microsoft Excel

Preferred Qualifications

• Experience using MD-Staff credentialing software

Benefits

In addition to your salary, we offer benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).

Pay

The salary for this role will range from $91,700 to $163,700 annually based on full-time employment. Pay is based on several factors including but not limited to local labor markets, education, work experience, and certifications.